MEDICARE: KEELEY FLAVIN MSDH, BSDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	H10122	MN

General Provider Information

NPI Number	:	1396425021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEELEY FLAVIN MSDH, BSDH

Provider Business Mailing Address
First Line	:	14111 ROSEWOOD LN N
Second Line	:
City	:	DAYTON
State	:	MN
Zip	:	55327-9720
Country	:	US
Telephone Number	:	952-457-0457
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 NICOLLET MALL STE 1737
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55402-2704
Country	:	US
Telephone Number	:	612-332-1164
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2023
Last Update Date	:	07/18/2023

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